INTRODUCTION — While the same standards of obstetric care apply whether patients are living in correctional facilities or the community, the risk factors associated with incarceration and the operating systems of correctional facilities create specific challenges to the provision of routine obstetric care for inmates. These include difficulties with communication and transportation, implementation of care plans, follow-up of abnormal tests, and guardianship for newborns after delivery.

This topic will discuss issues encountered in caring for incarcerated pregnant women. Our recommendations are generally consistent with guidance provided by the American College Of Obstetricians and Gynecologists [1]. While much of the discussion is based on data and experience from the United States, the general care principles may be applicable to other locations. Topics on general medical care in correctional facilities, routine prenatal care, and the impact of maternal incarceration on children are presented separately.

●(See "Clinical care of incarcerated adults".)

●(See "Prenatal care: Initial assessment" and "Prenatal care: Second and third trimesters" and "Prenatal care: Patient education, health promotion, and safety of commonly used drugs".)

●(See "Developmental and behavioral implications for children of incarcerated parents".)

EPIDEMIOLOGY — The female inmate population has grown at a rate double that of men in many countries [2-4]. Although the number of female prisoners in the United States increased by over 700 percent since 1980, the number of women incarcerated in state and federal correctional facilities has decreased by 2.6 percent between 2007 and 2017 (from 114,311 in 2007 to 111,360 in 2017) [5]. Data on pregnancy and incarceration are limited because of variable reporting requirements and inconsistent pregnancy testing upon entry to correctional facilities. In the United States, approximately 4 percent of women in state prisons were pregnant between 2016 and 2017 [6].

SPECIAL CONSIDERATIONS

Pregnancy testing — Policies on screening for pregnancy as women enter the correctional system vary by institution. The National Commission on Correctional Health Care (NCCHC) and the American College of Obstetricians and Gynecologists advise offering pregnancy testing to all women under the age of 55 [7,8]. In addition, the NCCHC advises repeat testing two weeks later (in case the first test was performed before the human chorionic gonadotropin level was detectable) and as needed for those female inmates who remain at risk of pregnancy (eg, conjugal visits from spouses, leaves of absence during incarceration) [7].

Pregnancy testing upon entry to the correctional system allows for timely counseling regarding possible emergency contraception, prenatal care, triage of pregnant women with obstetric or medical concerns (eg, vaginal bleeding, possible ectopic pregnancy, opiate withdrawal), and pregnancy termination. (See "Emergency contraception" and "Ectopic pregnancy: Clinical manifestations and diagnosis".)

Staff and patient communication — To ensure that the patient receives the care she needs, communication needs to occur among the on- and off-site medical staff, patient, and security staff. On-site medical staff tends to establish treatment schedules and ensure feasibility of treatment plans (for both on- and off-site visits). The inmate is then given permission per facility protocol (a written document or entry in a computerized inmate management system) that allows her to leave her unit or other duties in the correctional facility to visit the medical unit at specified times for on-site care.

Officers and on-site clinicians who do not regularly provide prenatal care for incarcerated women may need to be advised on activity restrictions (eg, types of work assignments), safety (eg, use of the bottom bunk bed, violence among inmates, restrictions on shackling such as no leg restraints), and nutritional requirements and interventions (eg, prenatal vitamin supplementation, continuous access to hydration, small frequent meals, special diets such as for gestational diabetes).

Most facilities request that future off-site appointments are communicated to the on-site health care providers so future transport can be arranged. Inmates are typically not told of their future off-site appointment dates for security reasons.

While the resources of correctional systems vary, we have found the following approach enables expedient care for the pregnant woman and successful communication among health care providers and correctional staff:

●Upon entry into a correctional facility, a women's health provider enters routine pregnancy restrictions into the inmate management system that can be viewed by correctional officers and other on-site medical staff. The restrictions are active for the duration of pregnancy and for six weeks after the estimated date of delivery. This process occurs within 24 to 72 hours of arrival.

●If on-site prenatal providers are not present when a new patient arrives, orders for routine prenatal care and medications (eg, prenatal vitamins, acetaminophen, anti-emetics) are reviewed by the admissions nurse with the on-call medical provider so patients can receive necessary treatments in a timely fashion. Appropriate pregnant patients may have certain medication orders approved for "keep on person" status, which allows the woman to take a supply of medication with her rather than returning to the medication line every time those drugs are needed.

●Electronic health records allow correctional staff and medical providers to communicate. The correctional staff can view the dates, times, and locations of all inmate appointments (eg, court dates, medical appointments, mental health appointments or group sessions, childbirth classes [where available], or work assignments).

●For appointments at off-site facilities, the off-site providers place their notes and any follow-up appointment information in a sealed medical documents folder that the correctional officer carries back to the facility. The medical documents folder is then given to the nursing staff or a medical provider who ensures information about future appointments is entered into the inmate management system. If questions arise regarding the ability of the correctional facility to meet the requirements of the treatment plan, the correctional staff contacts the on-site women's health nurse practitioner.

●At times, incarcerated patients will ask the off-site obstetrics provider to authorize or request special privileges such as extra blankets, pillows, or food. We have found that if the off-site providers communicate these requests with on-site medical staff, the latter will review such requests with the correctional staff to make sure those special privileges are considered in the correctional setting to be medically necessary.

HIPAA compliance — Under the Health Insurance Portability and Accountability Act (HIPAA), an inmate's medical information is deemed protected health information (PHI) [9]. An off-site clinician can share medical information with the correctional facility if the PHI is necessary for the provision of health care or to protect the health and safety of the individual or other inmates.

Correctional officers should never be used to communicate between off-site and on-site providers as they are not health care providers nor are they held to HIPAA standards. During a prenatal visit, the clinician may have to request that the correctional officer leave the room for examinations, procedures, or delivery to ensure the patient's privacy. However, a correctional officer's presence may be necessary in some situations, such as security or escape issues.

Consent for medical procedures — The process of obtaining patient consent for medical treatment or procedures is the same in correctional settings as in community settings. Inmates have autonomy: the right to make informed health care decisions, including refusal of medical care if they are deemed to have the capacity to make this decision. Specific to the correctional setting, inmates may be banned from consenting to postpartum sterilization because of historic concerns around coercive sterilization. (See 'Contraception' below.)

Pregnancy termination — While incarcerated, women retain a legal right to abortion services, but individual experience varies by the state, region, and facility [10,11]. Full access to services, including appointments, transportation, and payment, is not always available. For example, state and federal prisons may be prohibitively distant from an abortion clinic (75 to 383 miles) [12].

Most correctional facilities do not pay for abortion-related services. Therefore, incarcerated women, who have limited opportunities to save or borrow money while in custody, must rely on private savings or must seek a donor through nonprofit sources [10,13]. Pregnancy termination procedures are considered an outpatient service, and in certain locations the costs are covered either by the health care vendor contracted by the Department of Corrections (DOC) or the DOC itself if there is no vendor. Hospital admissions of greater than 24 hours can be billed to Medicaid. The Hyde Amendment prohibits the use of federal dollars to fund abortions, which affects women in the custody of the Federal Bureau of Prisons.

In our practice setting, abortion care is provided through our safety net hospital, and every attempt is made to provide same-day services (eg, counseling and, if desired, an abortion procedure at the same visit) to minimize patient discomfort and potential transportation challenges.

Transportation — Prenatal care of incarcerated women is generally shared between on-site and community-based clinicians. Thus, transport to nearby medical facilities is typically needed for portions of routine care (eg, ultrasound for fetal anatomic survey) or to manage high-risk or complicated pregnancies. Transportation to and from an outside medical facility can be stressful, and some women decline outside medical care for this reason. Potential stressors include long wait times to pass through security systems, embarrassment about being seen in public in inmate uniforms and restraints, and the need to be strip searched on return to the correctional facility. Transportation to appointments can be further complicated by unanticipated lockdowns that halt inmate movement through and out of the facility.

When caring for incarcerated women with high-risk problems, the amount of time required for the entire transport process needs to be factored into management plans. With the onset of a medical problem or emergency, the patient generally needs to contact a correctional officer, who will then contact a nurse, who will contact a clinician or other health care professional with obstetric experience before the decision is made to evaluate or transfer the patient. Additional time is required for passage through the security systems. These events occur before the patient is on her way to the outside medical facility, which could be a significant distance from the correctional facility where she is housed.

Continuity of care — While an estimated 1400 women per year deliver while incarcerated in the United States [7], most pregnant women will be released prior to delivery. Upon leaving a correctional facility, obstacles to continuity of care include lack of stable housing, transportation, and financial challenges (eg, lack of income, savings, or support from friends or family to pay for food and shelter).

To help ensure that time-sensitive tests (eg, ultrasound, laboratory tests) or frequent treatments (eg, progesterone injections to reduce the risk of preterm birth) occur on schedule, we take the following approach:

●Provide intensive assistance to help reactivate a patient's health insurance prior to release.

●When possible, share all follow-up appointment dates with the inmate immediately prior to release and explain the purpose, and importance, of each. This transfer of information may not be possible if an inmate is released directly from court.

●Where possible, schedule follow-up care with the same provider or health care facility that managed the woman's care during incarceration. For women who cannot follow up with the prior care provider, we make every attempt to transfer their care and records prior to their release to the inmate's preferred prenatal provider.

●Encourage correctional facilities to provide patients with medication in hand to bridge pregnant women to their next appointment. If medication cannot be released, the on-site medical staff can fax or call in prescriptions to outside pharmacies to be filled. In our experience, prescriptions are best written by the on-site medical staff as they have the most accurate information as to when the patient may be released from the facility (the individual often does not have this information). Institutional policies vary regarding provision of medication upon release [14].

●For women receiving methadone or buprenorphine, we contact an accessible treatment clinic or approved provider prior to the patient's release from the correctional facility. Methadone clinics typically require very specific documentation from the medical providers in the correctional facility, including a letter documenting the patient's last methadone dose.

PROVISION OF ROUTINE PRENATAL CARE — Incarcerated individuals are entitled to health care under the Eighth Amendment of the United States Constitution [15]. Policies regarding pregnancy-related health care for female inmates vary among states [16] and countries [2,17-20]. Several organizations, including the Federal Bureau of Prisons [21], the National Commission on Correctional Health Care [7,22], and the American College of Obstetricians and Gynecologists [8], have proposed minimal standards for pregnancy-related health care in correctional settings.

●Genetic counseling and testing – Obstetric standards for genetic counseling, genetic screening, and diagnostic testing are the same for incarcerated women and women in the community.

However, abnormal test results create additional challenges for incarcerated women because they have decreased or no contact with family and friends, and therefore limited psychosocial support. The father of the baby may not be available for genetic testing, which is sometimes important when the maternal result is abnormal. In addition, incarcerated women have reduced access to information on the test/disease as correctional facilities typically have limited library resources and no internet access for inmates. For these reasons, clinicians are advised to discuss abnormal test results, provide counseling services, and offer diagnostic testing during the same visit, if possible, or as expediently as possible.

●Ultrasound examination – Ultrasound examination for confirming or revising the estimated date of delivery, screening for congenital anomalies and short cervical length, and fetal surveillance (growth, well-being) follows the same guidelines as for nonincarcerated women. Given the challenges of scheduling and transportation, efforts should be made to provide immediate counseling and support for abnormal test results.

●RhD status – All pregnant inmates undergo an early maternal blood type with antibody screen as a part of their routine prenatal care. Intravenous drug abuse, particularly the practice of needle sharing, is a risk factor for alloimmunization to RhD and non-RhD red blood cell antigens. RhD-negative women without RhD alloantibodies receive anti-D immune globulin for routine indications (eg, bleeding during pregnancy) and as prophylaxis at 28 weeks of gestation. (See "RhD alloimmunization: Prevention in pregnant and postpartum patients".)

Consultation with a maternal-fetal medicine specialist is desirable for pregnancies complicated by alloimmunization. (See "RhD alloimmunization in pregnancy: Management" and "Management of non-RhD red blood cell alloantibodies during pregnancy".)

●Childbirth education and support – Education about labor and delivery is especially important for women who will deliver while incarcerated because they typically must labor or undergo cesarean delivery without the presence of family, friends, or a partner for support.

Childbirth education in the correctional facility can help reduce anxiety about the birth process and prepare the woman for returning to the correctional facility without her child. Models of childbirth education include facilitated group discussions [23] and doula visits to the correctional facility [24].

The authors' institution offers every patient who will deliver while still in custody a doula (at no cost) who speaks their language and provides support during labor or cesarean delivery.

SPECIFIC MEDICAL CONCERNS

Pregnancy-related complications — Incarcerated women tend to have complicated and/or high-risk pregnancies. Contributing factors include low socioeconomic status, late or no previous prenatal care, current or prior trauma (physical, sexual, and psychological), illicit drug and/or excessive alcohol use, smoking, mental health disorders, chronic illness, and acute or chronic infectious diseases [25-30]. As in any pregnancy, each patient is assessed for risk factors for adverse pregnancy outcome and monitored and treated as appropriate for the clinical situation.

Medical complications of pregnancy that require special treatment plans are particularly challenging for incarcerated women because inmates have limited access to medical facilities and difficulties with transportation. As an example, inmates are typically required to go to a medical unit every time a glucose level needs to be checked because medical equipment such as lancets can pose a security risk. The timing and frequency of access to the medical unit for procedures, such as glucose or blood pressure monitoring, can be restricted by the need for a nurse or correctional officer to call and escort the woman to the medical unit.

To help overcome these obstacles and facilitate the communication of critical or complex care plans, we advise appointing a medical liaison to oversee medical conditions that are primarily managed by off-site practitioner(s). The medical liaison can communicate changes in the care plan with the facility clinicians, answer questions for the inmate or correctional staff, and help resolve system challenges or failures. In our practice, our liaison is a team composed of a women's health nurse practitioner who is based entirely in the correctional facility, as well as an obstetrician-gynecologist who primarily works at the off-site hospital where incarcerated patients will deliver and comes to the correctional facility on a weekly basis to provide care.

Infectious disease

●Sexually transmitted infections – Tests for the following sexually transmitted infections are performed routinely at the first prenatal visit and then repeated in the third trimester for women who are at high risk: syphilis, hepatitis B antigen, hepatitis C antibody, HIV, chlamydia, and Neisseria gonorrhoeae. Incarcerated women also benefit from routine Trichomonas vaginalis testing. In a cross-sectional analysis of data from 205 women entering a correctional facility in Rhode Island who were at risk for an unplanned pregnancy, one-third tested positive for gonorrhea, chlamydia, or trichomonas [31]. As these women are also at increased risk of human papilloma virus (HPV) infection, cervical cytology and HPV testing is performed if not up-to-date. (See "Prenatal care: Initial assessment", section on 'Laboratory tests'.)

●HIV – HIV testing is routinely performed for pregnant women unless the woman declines (opt-out) [32]. Repeat testing is recommended for incarcerated and other high-risk women in the third trimester, preferably before 36 weeks.

According to the Bureau of Justice, there were 1220 female inmates with HIV or acquired immunodeficiency syndrome (AIDS) in state and federal prisons in 2015 [33]. Approximately one-third were admitted in states that conducted mandatory HIV testing, and an additional 31 percent were admitted in states with opt-out HIV testing during intake. (See "Screening and diagnostic testing for HIV infection" and "Clinical care of incarcerated adults", section on 'Testing for HIV'.)

●Vaccination – In addition to testing for infections, routine antepartum vaccinations (eg, influenza and Tdap) are particularly important for incarcerated women as they have little to no control over their exposure to others with respiratory illness. Postpartum, other vaccinations (eg, human papillomavirus; measles, mumps, and rubella [MMR]; varicella) should be given, as appropriate. (See "Immunizations during pregnancy", section on 'Routine prenatal immunizations' and "Immunizations during pregnancy", section on 'Postpartum immunization'.)

Mental health — Approximately two-thirds of incarcerated women report a history of mental health problems, and 20 percent meet the threshold for recent serious psychological distress [34]. Symptoms can be exacerbated by the stress of being incarcerated, pregnant, or both [35-37]. Among the consequences of mental health disorders, inmates who reported a mental health problem were twice as likely as those without to have been injured in a fight during incarceration in one study (20 versus 10 percent) [38]. The impact of inmate violence is compounded when the inmate is pregnant since abdominal trauma can cause abruption.

As in the community, pregnant incarcerated women should be screened and treated for mental disorders, particularly depression, both during and after pregnancy [7,39]. Those with a known diagnosis or who screen positive should be evaluated by a mental health specialist. Referral for mental health evaluation can be initiated by both medical and correctional staff. The request for evaluation is then triaged based on urgency. In our facility, inmates who do not require urgent care are seen within two weeks of the request.

Medical treatment of mental health disorders must balance the risks and benefits of medication compared with no treatment for both the mother and the fetus (or infant for breastfeeding women). (See "Antenatal depression: Pregnancy and neonatal outcomes" and "Unipolar major depression in pregnant women: General principles of treatment" and "Teratogenicity, pregnancy complications, and postnatal risks of antipsychotics, benzodiazepines, lithium, and electroconvulsive therapy" and "Bipolar disorder in pregnant women: Screening, diagnosis, and choosing treatment for mania and hypomania".)

Suicide rates are markedly lower among pregnant inmates; the rate is estimated to be half of that observed for nonpregnant female inmates [40]. Although pregnancy appears to reduce the rate of suicide, the protective effect may be diminished if the pregnancy is undesired or if the pregnancy ends in miscarriage or stillbirth [41]. (See "Clinical care of incarcerated adults", section on 'Prevention of suicide and self-harm'.)

Physical and sexual trauma — A history of physical and/or sexual trauma, and especially complex or repeated trauma, is common amongst inmates, particularly women [36]. We advise a trauma-informed approach to care of all female inmates to promote autonomy and reduce retraumatization. (See "Human trafficking: Identification and evaluation in the health care setting", section on 'Trauma-informed care'.)

To prevent sexual violence, the United States has federal laws (Prison Rape Elimination Act of 2003 [PREA]) to prevent, detect, and respond to sexual abuse in correctional facilities [42]. (See "Clinical care of incarcerated adults", section on 'Sexual violence'.)

Substance use and treatment

●Tobacco use – A study of two United States urban prisons reported daily smoking rates of 42 and 91 percent for incarcerated women [43]. To improve overall health, United States correctional facilities are increasingly becoming smoke-free. Smoking cessation should be encouraged and cessation programs should be offered to all women who wish to stop smoking. (See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options".)

●Drug and alcohol use disorders – In a sample of prisons and jails in the United States participating in the Pregnancy in Prison Statistics (PIPS) study, 26 percent of pregnant individuals admitted to prisons and 14 percent of those admitted to jails had opioid use disorder [44]. In a National Inmate Survey, approximately 70 percent of incarcerated women met criteria for drug (including alcohol) dependence or abuse, but pregnancy status was not identified [45]. The high rates of drug and alcohol use, and the potential life-threatening complications from withdrawal, highlight the need for screening and treatment of substance use disorders. (See "Substance use during pregnancy: Screening and prenatal care", section on 'Screening for substance use' and "Alcohol intake and pregnancy".)

●Treatment of opioid use disorder – Approximately one-quarter of incarcerated individuals take part in some kind of drug treatment program, including self-help and peer counseling programs [45]. While incarcerated pregnant women and their developing fetuses benefit from the reduction in access to addictive substances [46], acute opiate withdrawal during pregnancy may have adverse fetal effects; therefore, pregnant women with an opioid use disorder should be transitioned to medication-assisted treatment with methadone or buprenorphine, as available in their setting. Treatment may require daily transport of inmates to an off-site methadone clinic. (See "Overview of management of opioid use disorder during pregnancy" and "Methadone and buprenorphine pharmacotherapy of opioid use disorder during pregnancy".)

Treatment programs may also reduce relapse, and therefore recidivism, upon release. Once discharged from a correctional facility, women on maintenance therapy require prompt follow-up at an outpatient treatment center. Former inmates with a history of opioid use disorder are at an increased risk of death from an overdose compared with the general population [2,47]. Specific education about access to and use of naloxone is essential for inmates who are being released. (See "Clinical care of incarcerated adults", section on 'Opioid use disorder' and "Prevention of lethal opioid overdose in the community".)

Although pharmacotherapy with either methadone or buprenorphine is the recommended treatment for opioid use disorder during pregnancy, in the sample of prisons and jails in the United States participating in the PIPS study mentioned above, nearly one-third of pregnant inmates were managed by withdrawal, usually when the inmate was not already on pharmacotherapy prior to incarceration [44]. Two-thirds of the prisons and three-quarters of the jails providing pharmacotherapy for opioid use disorder in pregnancy discontinued it postpartum, although continuation reduces relapse and its consequences among those who will be getting released. (See "Overview of management of opioid use disorder during pregnancy".)

Diet and nutrition — Many states do not require correctional facilities to provide appropriate nutrition for pregnant women [48]. Correctional facilities housing pregnant women should have pregnancy diets [49], which exclude cold cuts, unpasteurized foods, and raw or undercooked meat due to risk of Listeria and toxoplasmosis. All pregnant women should receive folic acid supplements containing 400 to 800 mcg of folic acid for prevention of neural tube defects. Women with anemia should be provided with iron supplementation. Many incarcerated pregnant women receive prenatal vitamins, which typically contain folic acid and iron. (See "Nutrition in pregnancy: Dietary requirements and supplements".)

Incarcerated women may have more problems with pregnancy-associated nausea and vomiting because they cannot control the timing of their meals, type of food that is available, and access to fluid. High-protein snacks and bland diets have been reported to be helpful, but inmates may only be able to purchase less healthy snacks with commissary (canteen) funds, if available. Therefore, correctional facilities are advised to provide snacks outside of scheduled meal times and dietary flexibility (bland diets, high-protein snacks) for inmates experiencing pregnancy-associated nausea. Access to fluid should be available at all times. Ideally, women should also have access to scheduled antiemetic drugs. (See "Nausea and vomiting of pregnancy: Treatment and outcome".)

INTRAPARTUM RESTRAINTS (SHACKLING) — The use of restraints, or shackles, during pregnancy, labor, delivery, and postpartum is an incompletely resolved and controversial matter. Although the United Nations Bangkok Rules [2]; recommendations of government, medical, and legal societies [50-53]; and laws [54] state that restraints should only be used on pregnant inmates in extreme circumstances and that restraints should never be used on women during labor and delivery [2,50,54], the actual experience of pregnant inmates may differ. In addition, existing anti-shackling laws often have grey areas with regards to use of restraints on pregnant women in transit or while in an off-site facility (including admission to a hospital, visit to an outside clinic, or court appearance) during the antepartum and postpartum periods [55].

Concerns about shackles and handcuffs include that they can increase the risk of a fall, can prevent a woman from breaking a fall with her hands, and generally discourage ambulation. Abdominal trauma incurred during a fall can potentially cause placental abruption, which can lead to preterm labor and other adverse effects. To promote patient health and safety in regions where restraints are used, clinicians should discuss the risks to the woman and fetus with corrections facility administration and advocate for total adherence to existing anti-shackling laws and recommendations.

PREGNANCY OUTCOME — Although a systematic review of pregnant women in developed countries imprisoned at any point during pregnancy reported that they are at higher risk for preterm delivery and low birth weight than the general obstetric population [56], when compared with similarly disadvantaged obstetric populations, maternal and fetal outcomes actually improve with increasing lengths of incarceration (eg, less preterm birth and growth restriction, higher birth weight). The improved outcomes may reflect the effects of regular prenatal care, stable housing, provision of meals, better physical security, and a reduction in drug and alcohol use. However, access to and quality of prenatal care from prison to prison are variable, and individual prison systems and pre-incarceration conditions may play a role in pregnancy outcome [4].

On average, for each day spent incarcerated while pregnant, an infant's birth weight increases by 1.49 g compared with infants born to women incarcerated at times other than during their pregnancies [57]. In addition, compared with disadvantaged women living in the community, incarcerated women had a lower risk of stillbirth (odds ratio [OR] 0.35, 95% CI 0.14-0.84) and low birth weight (OR 0.57, 95% CI 0.35-0.93) [56]. These outcomes appear to be influenced by the timing of incarceration during pregnancy, racial differences, and amount of prenatal care [58-61].

More recent data were reported in a prospective study on pregnancy outcome among 1396 pregnant women in United States state and federal prisons in 2016 to 2017 [4]. Overall outcome was favorable, with live birth in 92 percent (6 percent were preterm), miscarriage in 6 percent, abortion in 1 percent, stillbirth in 0.5 percent, newborn death in 0.5 percent, and no maternal deaths. The gestational age at prison entry was not available, which could bias the findings since gestational age at study entry could be expected to affect the prospective risk of some outcomes. The same group reported similar data for jails in the United States. Of the 224 pregnancies that ended in jail, 64 percent were live births, 18 percent were miscarriages, 15 percent were induced abortions, and 1.8 percent were ectopic pregnancies. The preterm birth rate was 8 percent [62].

POSTPARTUM ISSUES

Newborn placement — Most newborns will be separated from their mothers upon discharge from the hospital. Few correctional facilities offer on-site nursery programs. Child placement options are typically limited to family, friend, foster care, and adoption. For women likely to deliver while in custody, parenting and child custody services should be available in the correctional institution to facilitate guardianship planning prior to delivery [22]. When advanced planning is not possible, the patient may have to wait until she has access to hospital social workers at the time of delivery.

Breastfeeding — Following the birth of her child, an inmate will usually spend two (for a vaginal birth) to four (for a cesarean birth) days in the hospital prior to transport back to the correctional facility. Mothers who are eligible for contact with their infant may elect to breastfeed while in the hospital. This may require collaboration among correctional officers, obstetrics staff, newborn nursery/neonatal intensive care unit staff, and social workers to support her efforts. Upon discharge, medical providers in the correctional facility should be prepared to help the woman anticipate engorgement and identify signs of mastitis.

Prolonged breastfeeding is rarely an option given the lack of widespread on-site nurseries that would allow for newborns to remain with their mothers while still in custody. If there will only be temporary separation between the mother and her infant due to imminent release, a correctional facility may be able to make special arrangements for an inmate to pump and discard the milk in order to preserve her milk supply.

Some facilities have successful programs that allow incarcerated mothers to pump breast milk and have it stored until it can be picked up by the infant's guardian [7]. However, most facilities do not have the infrastructure to support prolonged pumping due to: (1) lack of privacy for inmates to pump, given shared cells and the need for correctional officers to maintain visual contact with inmates; (2) concern for potential self-harm or creation of weapons with parts of electric breast pumps (but hand pumps are an alternative); and (3) lack of storage protocols for breast milk, considered a potential hazardous bodily fluid.

Contraception — Contraceptive options, including immediate postpartum placement of long-acting reversible contraception (LARC), are discussed as part of routine prenatal care. For incarcerated women, contraceptive counseling also addresses the planned duration of imprisonment and any state laws that may ban permanent sterilization procedures [63,64]. When contraception is offered at no cost while a patient is still incarcerated, women are 15 times more likely to start a method than if it is offered at no cost in the community [65].

Women who are not offered a contraceptive are at increased risk of an unintended pregnancy. In one study, approximately half of a group of previously incarcerated women conceived within 90 days of leaving the correctional facility [66]. In another study, 84 percent of incarcerated women who had been pregnant reported having an unintended pregnancy and 85 percent said it was likely that they would have sexual relations with a man within six months after release [67].

Prior to release to the community, women can be given referral information for their ongoing contraceptive needs. One option is community-based Title X services (United States federally funded services for reproductive health targeting poor and underserved populations). Provision of emergency contraception is another option. In one study, 71 percent of female inmates said they would accept an advance supply of emergency contraception upon release from the correctional facility [68]. Another option is creating an infrastructure within the prison for prerelease women's health visits that include sending a prescription for the first few months of the pill/patch/ring to a pharmacy close to where the patient will release, administering a depot medroxyprogesterone acetate injection to cover the first three months after discharge, or provision of LARC prior to release, as patient's medical history and contraceptive preferences dictate. (See "Contraception: Counseling and selection".)

CHILDREN OF INCARCERATED MOTHERS — In United States prisons, 62 percent of women are mothers of children under age 18 [69]. In the month prior to arrest, approximately half of women lived with their minor aged children and 75 percent of those women living with children were in single-parent households [25,56,69]. Once incarcerated, 37 percent of women reported that a child lived with the other parent, 45 percent lived with grandparents, 30 percent lived with other family or friends, and 11 percent of women had a child in foster care [69]. Foster care placement can be particularly stressful for women and their children because incarcerated mothers risk losing their parental rights if they are unable to meet court-mandated family reunification requirements for contact and visitation with their children [70].

Arrest and incarceration of a parent is a unique stress for affected children. In addition to this stress, poverty, parental substance use and mental illness, domestic violence, and inconsistent or unavailable caregivers put these children at risk for behavioral and developmental problems. (See "Developmental and behavioral implications for children of incarcerated parents".)

The familial disruption and risk to child welfare posed by incarceration has led several advocacy groups to call for alternatives to custodial terms and reduction of unnecessary imprisonment. Until such changes can be achieved, guidelines such as the United Nations Bangkok Rules promote the creation of maximum opportunities for incarcerated mothers to meet with their children as long as "public safety is not compromised" [2]. Family-centered services in correctional facilities can help parents use their sentence to strengthen their parenting skills, foster continued bonds with their children, and access community supports to assist them upon release.

RESOURCES FOR CLINICIANS

●American College of Obstetricians and Gynecologists (ACOG) – ACOG recommended health care for pregnant and postpartum incarcerated women.

●National Women's Law Center – A nonprofit organization dedicated to protecting and promoting equality and opportunity for women and families.

●American Civil Liberties Union – A nonprofit organization dedicated to defending and preserving individual rights and liberties guaranteed by the Constitution and laws of the United States.

●National Commission on Correctional Health Care – The National Commission on Correctional Health Care is a nonprofit private association that provides recommendations for the management of a correctional health services system, including care and treatment, health records, administration, personnel and medical-legal issues.

●American Correctional Association – The American Correctional Association is nonprofit private association committed to improving practices in correctional systems by helping agencies provide correctional populations with safe and effective health service delivery.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General prenatal care" and "Society guideline links: Health care of criminal justice-involved populations".)

SUMMARY AND RECOMMENDATIONS

●Data on pregnancy and incarceration are limited because of variable reporting requirements and inconsistent pregnancy testing upon entry to correctional facilities. In the United States, approximately 4 percent of incarcerated women are pregnant. (See 'Epidemiology' above.)

●Pregnancy screening upon entry to a correctional setting allows for timely counseling regarding prenatal care, triage of pregnant women with obstetric or medical concerns(eg, vaginal bleeding, possible ectopic pregnancy, opiate withdrawal), or pregnancy termination. (See 'Pregnancy testing' above.)

●We advise communicating the care plan with the patient and correctional facility medical staff.

●Under the Health Insurance Portability and Accountability Act (HIPAA), an inmate's medical information is deemed protected health information (PHI). An off-site clinician can share medical information with the correctional facility if the PHI is necessary for the provision of health care or to protect the health and safety of the individual or other inmates. Correctional officers should never be used to communicate between off-site and on-site providers as they are not health care providers nor are they held to HIPAA standards. (See 'HIPAA compliance' above.)

●Transport to nearby medical facilities is typically needed for portions of routine care (eg, surveillance ultrasounds) or to manage high-risk or complicated pregnancies. Transportation to and from an outside medical facility can be stressful, which can cause some women to decline outside medical care. When caring for incarcerated women with high-risk problems, the amount of time required for the entire transport process needs to be factored into management plans. (See 'Transportation' above.)

●Most incarcerated pregnant women will be released prior to delivery. On leaving a correctional setting, obstacles to continuous care include lack of stable housing and financial challenges. Steps that help ensure continuity of care after release include reestablishing medical insurance, scheduling follow-up appointments, transferring health care records to the outside providers, and providing bridge medication or prescriptions to cover the woman's needs until her next scheduled appointment. For women receiving methadone or buprenorphine for opiate use disorder in pregnancy, continuity of care includes ensuring services with an accessible treatment clinic or approved provider prior to the patient's release from the correctional facility. (See 'Continuity of care' above.)

●Obstetric standards for prenatal care, including genetic counseling, genetic screening, diagnostic testing, and ultrasound surveillance, are the same for incarcerated women as for women in the community. Incarcerated women are considered high risk for many infectious diseases where retesting in the third trimester is recommended. (See 'Provision of routine prenatal care' above.)

●High-risk or complicated pregnancies are common in incarcerated women. Contributing factors include low socioeconomic status, no or inadequate prenatal care, current or prior trauma (physical, sexual, and psychological), illicit drug and/or alcohol abuse, mental health disorders, chronic illness, and acute or chronic infectious diseases. As in any pregnancy, each patient is assessed for complicating risk factors and monitored and treated as appropriate for the clinical situation. (See 'Pregnancy-related complications' above.)

●Although multiple legal and medical bodies advise that restraints should only be used on pregnant inmates in extreme circumstances and that restraints should never be used on women during labor and delivery, the actual experience of pregnant inmates may differ. In addition, existing anti-shackling laws often have grey areas with regards to use of restraints on pregnant women in transit or while in an off-site facility (including admission to a hospital, visit to an outside clinic, or court appearance) during the antepartum and postpartum periods. (See 'Intrapartum restraints (shackling)' above.)

●Education about postpartum issues, including newborn placement, breastfeeding, and contraception, is begun during the prenatal care process. Most newborns will be separated from their mothers upon discharge from the hospital, and prolonged breastfeeding through pumping and storage is rarely an option. (See 'Postpartum issues' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jennifer G Clarke, MD, MPH, who contributed to an earlier version of this topic review.